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Outpatient transoral laser vaporization of anterior glottic webs and keel placement: Risks of airway compromise
Journal of Voice Vol. 12, No. 4, pp. 536--539 © 1998 Singular Publishing Group. Inc.
Outpatient Transoral Laser Vaporization of Anterior Glottic Webs and Keel Placement: Risks of Airway Compromise Roy R. Casiano and Donna S. Lundy Depart~nent of Otolaryngolog3; UniversiO, of Miami School of Medichle, Miami, Florida
Summary: Management of acquired anterior glottic webs involves resection of the web with reconstitution of a linear vocal fold edge and anterior commissure. Traditional procedures such as transcervical midline thyrotomy (with tracheostomy) and keel placement have been used for patients with extensive scar formation and airway compromise. However, in selected patients with more limited scarring and minimal-to-no airway compromise, a transoral endoscopic approach may be a viable option. In three patients, transoral laser vaporization followed by transoral keel placement and outpatient removal resulted in a vocal quality that perceptually improved without any evidence of respiratory compromise postoperatively. Key Words: Anterior glottic web--Keel placement-Transcervical midline thyrotomy.
In the adult population, anterior glottic webs can be a difficult challenge for the laryngologist. Most are iatrogenic and occur after endotracheal intubation and/or laryngeal surgery. Treatment involves resection of the scar band with reconstitution of a linear vocal fold edge and anterior commissure. The degree of voice improvement after surgery is usually dependent on the degree of intracordal fibrosis and web reformation. In more severe circumstances, patients remain significantly hoarse despite some relative improvement.
Transcervical midline thyrotomy and keel placement has been the traditional treatment of choice in patients who are surgical candidates. 1,2 However, surgery involves an open procedure and a temporary tracheotomy is often necessary to deal with the postoperative edema that ensues. In 1924, Haslinger first described the technique of web excision followed by placement of a silver plate between the cords in the anterior glottis. 3 Since then, many authors have modified Haslinger's technique of transoral endoscopic placement of laryngeal keels. 4-12 However, most of these studies were on patients who had a preexisting tracheotomy. The direct effect of the keel on respiration in a patient without a tracheotomy is unknown. More recently, in 1994 Lichtenberger et al. presented a series of 12 patients without preexisting tracheotomy who underwent their method of transoral endo-extralaryngeal keel placement.13 Although it was noted that none of the patients required a tracheotomy, it was not reported whether any patient
Accepted for publication September 30, 1997. Address correspondence and reprint requests to Roy R. Casiano, M.D., Department of Otolaryngology, P.O. Box 016960 (D-48), University of Miami School of Medicine, Miami, FL 33101, U.S.A. This paper was presented at the 26th Annual Voice Foundation Symposium: Care of the Professional Voice, June 7, 1997, Philadelphia, Pennsylvania.
536
OUTPATIENT TRANSORAL LASER VAPORIZATION
experienced any degree of respiratory compromise. In addition, keel removal required a second direct laryngoscopy under general anesthesia. The efficacy of keel removal under local anesthesia with a flexible fiberoptic nasopharyngoscope in the clinic was not mentioned. The following report reviews the author's experience with three patients undergoing removal of glottic webs and transoral keel placement to evaluate its efficacy in terms of the degree of postoperative respiratory compromise, its ability to control web reformation, and vocal outcome. In addition, the effect on respiration of keel removal in the clinic under local anesthesia is evaluated. TECHNIQUE Laser excision of the glottic web is performed under general anesthesia utilizing the operating microscope under high magnification and a CO 2 laser. The goal is to reestablish the anterior commissure and linearity of the vocal fold vibratory edge while avoiding damage to the underlying vocalis muscle and vocal ligament. A keel is fashioned out of 0.2-mm to
v
537
0.4-mm thickness silastic sheeting. A 16-gauge needle is used as a conduit through which a 4.0 nylon suture is passed through the cricothyroid space below the anterior commissure and through the thyrohyoid space above the anterior commissure in the area of the petiole of the epiglottis (Figs. 1 and 2). The suture is withdrawn through the laryngoscope and tied to the corresponding superior and inferior edge of the prefashioned keel. The keel is fashioned so that its anterior-to-posterior length is no longer than the length of the membranous vocal fold. The cervical ends of the sutures are pulled firmly and used to guide the keel into position at the anterior commissure. Once the keel's position is confirmed through the laryngoscope, the sutures are tied over a rolled-up piece of silastic (Fig. 3). The patient is discharged home the day of the surgery. The keel is kept in place for 3 weeks. It is removed transnasally in the clinic with a flexible fiberoptic nasopharyngoscope under topical anesthesia, using transcricothyroid infiltration of 4% topical lidocaine into the trachea. Corticosteroids are used intraoperatively and for 5 days postoperatively.
7
FIG. 1. Placement of subglottic suture through the cricothyroid space.
J FIG. 2. Placement of supraglottic suture through the thyrohyoid space and attachment to the prefashioned silastic stent.
Journal of Voice, Vol. 12, No. 4, 1998
538
ROY R. CASIANO AND DONNA S. LUNDY
and breathiness was evaluated preoperatively and postoperatively on a 5-point scale (0 = normal, 1 = slight, 2 = mild, 3 = moderate, 4 = severe). Patients were interviewed daily for 3 days and then weekly for the presence of any postoperative baseline change in at rest symptoms or signs of airway complaints (i.e., increased shortess of breath on exertion, stridor, etc.), granuloma formation, and/or web re-formation. RESULTS
J
FIG. 3. Keel secured in place. Sutures tied over rolled piece of silastic and the external skin of the neck.
METHODS Three patients underwent transoral laser resection of their glottic webs over an 18-month period. Patient demographics, the etiology of web formation, the location and extent of the webs, and follow-up are listed in Table 1. Two patients had a web limited to the anterior third of the membranous vocal fold. In the other patient, two thirds of the vocal fold was involved. The etiology of injury was secondary to a multi-vehicle accident and subsequent intubation for one patient and to microlaryngoscopy and polyp removal with anterior commissure stripping in another patient. The third patient underwent emergent intubation for a small bowel obstruction 1 week after laryngeal laser vaporization of Teflon secondary to airway compromise. The subsequent web formation resulted in a considerably breathy and aphonic voice. The glottic web was rated according to the length of the vocal folds involved: type 1 (<50% of the membranous vocal fold), type 2 (the entire length of the membranous vocal fold), and type 3 (involvement of the membranous as well as cartilaginous vocal folds). Patients underwent preoperative and postoperative videostroboscopy (Kay Elementrics), as well as acoustical analysis, glottal flow measures, and perceptual analysis. The degree of hoarseness Journal of Voice, Vol. 12, No. 4, 1998
All three patients tolerated the keel well without any significant airway compromise. None of the patients complained of increased shortness of breath. All of the patients had improvement of their voices by perceptual measures (Table 2). However, only patient 1 experienced a dramatic improvement (objectively and perceptually) in her vocal quality. Her preoperative jitter (3.04), shimmer (1.20), and harmonic-tonoise ratio (1.18) all improved (1.27, 0.36, and 6.30, respectively). She had a type 1 web with a pinholesized opening preserving the anterior commissure. Patients 2 and 3 had slight improvement in their voices by perceptual measures only. Both patients had residual rounding of the anterior commissure without significant web re-formation. Patient 1 also had a solitary granuloma formation, which was removed subsequently on an outpatient basis. DISCUSSION Although the number of patients in this series is too few to make a conclusive judgment on the procedure, it appears that transoral placement of a glottic keel is safe and does not significantly interfere with respiration. However, voice results of transoral laser resection and keel placement are mixed. Patients with more severe fibrosis of the anterior commissure and the vibrating edge of the vocal fold may experience residual hoarseness despite adequate resection of the web and cord restoration. Other factors, such as the depth of the intracordal fibrosis, most likely play a significant role in these patients. The technique can be done safely on an outpatient basis, obviating the need for a transcervical approach and/or a tracheotomy. The keel may also be removed in the clinic with topical anesthesia and the aid of a nasopharyngoscope, utilizing the working channel and a small cupped forceps. The long-term results re-
OUTPATIENT TRAbISORAL LASER VAPORIZATION
539
T A B L E 1. Patient demographics, histo~. , and follow-up Follow-up (months)
Airway Compromise
Intubation 2-3 days
5
no
1
Direct laryngoscopy and polyp removal
2
no
2
Teflon laser vaporization and intubation 1 day
12
no
Patient
Age
Sex
Web type
I
42
F
2
2
68
M
3
65
M
Etiology
T A B L E 2. Preoperative and postoperative voice measures Preoperative
Postoperative
Patient
Hoarseness
Breathiness
1
3
3
Hoarseness
Breathiness
I
1
2
3
3
2
2
3
4
4
3
3
garding vocal quality and web re-formation are unknown. Further study is under way on a larger group of patients. In conclusion, the transoral endoscopic keel placement after web resection appears to be a safe alternative to transcervical approaches without any evidence of airway compromise.
REFERENCES I. McNaught RC. Surgical correction of anterior web of the larynx. Laryngoscope 1950;60:264. 2. Woodman D. Laryngeal stenosis. Lalyngoscope 1953;63:714 3. Haslinger E Ein Fall yon Membranbildung im Larynx. Eine neue Methode zu ihrer Behebung. Monatschr Ohrenheilk 1924;58:174. 4. Messerklinger W. Zur behandlung der kongenitalen synechien im glottisbereich. Monatschr Ohrenheilk 1964;98:194. 5. Mouney DE Lyons GD. Fixation of laryngeal stents. Lal3,ngoscope 1985;95:905-7.
6. Nessel E. Ein Vorschlag zur Vereinfachten Behandlung der Stimmlippensynechie. HNO 1968; 16:284 7. Dedo HH. Endoscopic teflon keel for anterior glottic web. Ann Otol Rhinol Lal3,ngol 1979;88:467. 8. Devgan BK, Lampros WP, Leach W. Endolaryngeal surgery for anterior glottic stenosis. Ear Nose Throat J 1976;55: 377-81. 9. Kleinsasser O. Mikrolal3,ngoskopie und Endolaryngeale Mikrochirurgie. Stuttgart, Germany: Schattauer, 1968. 10. Beck C. Einfache verfahren zur behandlung von stenosen der oberen luftwege. Arch Ohr Nas Kehlk Heilk 1962;180: 507. 1 I. Pennington CL. The treatment of anterior glottic webs: a reevaluation of Haslinger's technique. La~.ngoscope 1968;78: 728-41. 12. Alonso JM, Regules JE. Behandlung der angeborenen Membranen und der Synechien des vorderen Glotisabschnittes. Z La~ngol Rhhlol 1956;35:53. 13. Lichtenberger G, Toohill RJ. New keel fixing technique for endoscopic repair of anterior commissure webs. Latyngoscope 1994; 104:77 I-4.
Journal of Voice, Vol. 12, No. 4, 1998
Outpatient Transoral Laser Vaporization of Anterior Glottic Webs and Keel Placement: Risks of Airway Compromise Roy R. Casiano and Donna S. Lundy Depart~nent of Otolaryngolog3; UniversiO, of Miami School of Medichle, Miami, Florida
Summary: Management of acquired anterior glottic webs involves resection of the web with reconstitution of a linear vocal fold edge and anterior commissure. Traditional procedures such as transcervical midline thyrotomy (with tracheostomy) and keel placement have been used for patients with extensive scar formation and airway compromise. However, in selected patients with more limited scarring and minimal-to-no airway compromise, a transoral endoscopic approach may be a viable option. In three patients, transoral laser vaporization followed by transoral keel placement and outpatient removal resulted in a vocal quality that perceptually improved without any evidence of respiratory compromise postoperatively. Key Words: Anterior glottic web--Keel placement-Transcervical midline thyrotomy.
In the adult population, anterior glottic webs can be a difficult challenge for the laryngologist. Most are iatrogenic and occur after endotracheal intubation and/or laryngeal surgery. Treatment involves resection of the scar band with reconstitution of a linear vocal fold edge and anterior commissure. The degree of voice improvement after surgery is usually dependent on the degree of intracordal fibrosis and web reformation. In more severe circumstances, patients remain significantly hoarse despite some relative improvement.
Transcervical midline thyrotomy and keel placement has been the traditional treatment of choice in patients who are surgical candidates. 1,2 However, surgery involves an open procedure and a temporary tracheotomy is often necessary to deal with the postoperative edema that ensues. In 1924, Haslinger first described the technique of web excision followed by placement of a silver plate between the cords in the anterior glottis. 3 Since then, many authors have modified Haslinger's technique of transoral endoscopic placement of laryngeal keels. 4-12 However, most of these studies were on patients who had a preexisting tracheotomy. The direct effect of the keel on respiration in a patient without a tracheotomy is unknown. More recently, in 1994 Lichtenberger et al. presented a series of 12 patients without preexisting tracheotomy who underwent their method of transoral endo-extralaryngeal keel placement.13 Although it was noted that none of the patients required a tracheotomy, it was not reported whether any patient
Accepted for publication September 30, 1997. Address correspondence and reprint requests to Roy R. Casiano, M.D., Department of Otolaryngology, P.O. Box 016960 (D-48), University of Miami School of Medicine, Miami, FL 33101, U.S.A. This paper was presented at the 26th Annual Voice Foundation Symposium: Care of the Professional Voice, June 7, 1997, Philadelphia, Pennsylvania.
536
OUTPATIENT TRANSORAL LASER VAPORIZATION
experienced any degree of respiratory compromise. In addition, keel removal required a second direct laryngoscopy under general anesthesia. The efficacy of keel removal under local anesthesia with a flexible fiberoptic nasopharyngoscope in the clinic was not mentioned. The following report reviews the author's experience with three patients undergoing removal of glottic webs and transoral keel placement to evaluate its efficacy in terms of the degree of postoperative respiratory compromise, its ability to control web reformation, and vocal outcome. In addition, the effect on respiration of keel removal in the clinic under local anesthesia is evaluated. TECHNIQUE Laser excision of the glottic web is performed under general anesthesia utilizing the operating microscope under high magnification and a CO 2 laser. The goal is to reestablish the anterior commissure and linearity of the vocal fold vibratory edge while avoiding damage to the underlying vocalis muscle and vocal ligament. A keel is fashioned out of 0.2-mm to
v
537
0.4-mm thickness silastic sheeting. A 16-gauge needle is used as a conduit through which a 4.0 nylon suture is passed through the cricothyroid space below the anterior commissure and through the thyrohyoid space above the anterior commissure in the area of the petiole of the epiglottis (Figs. 1 and 2). The suture is withdrawn through the laryngoscope and tied to the corresponding superior and inferior edge of the prefashioned keel. The keel is fashioned so that its anterior-to-posterior length is no longer than the length of the membranous vocal fold. The cervical ends of the sutures are pulled firmly and used to guide the keel into position at the anterior commissure. Once the keel's position is confirmed through the laryngoscope, the sutures are tied over a rolled-up piece of silastic (Fig. 3). The patient is discharged home the day of the surgery. The keel is kept in place for 3 weeks. It is removed transnasally in the clinic with a flexible fiberoptic nasopharyngoscope under topical anesthesia, using transcricothyroid infiltration of 4% topical lidocaine into the trachea. Corticosteroids are used intraoperatively and for 5 days postoperatively.
7
FIG. 1. Placement of subglottic suture through the cricothyroid space.
J FIG. 2. Placement of supraglottic suture through the thyrohyoid space and attachment to the prefashioned silastic stent.
Journal of Voice, Vol. 12, No. 4, 1998
538
ROY R. CASIANO AND DONNA S. LUNDY
and breathiness was evaluated preoperatively and postoperatively on a 5-point scale (0 = normal, 1 = slight, 2 = mild, 3 = moderate, 4 = severe). Patients were interviewed daily for 3 days and then weekly for the presence of any postoperative baseline change in at rest symptoms or signs of airway complaints (i.e., increased shortess of breath on exertion, stridor, etc.), granuloma formation, and/or web re-formation. RESULTS
J
FIG. 3. Keel secured in place. Sutures tied over rolled piece of silastic and the external skin of the neck.
METHODS Three patients underwent transoral laser resection of their glottic webs over an 18-month period. Patient demographics, the etiology of web formation, the location and extent of the webs, and follow-up are listed in Table 1. Two patients had a web limited to the anterior third of the membranous vocal fold. In the other patient, two thirds of the vocal fold was involved. The etiology of injury was secondary to a multi-vehicle accident and subsequent intubation for one patient and to microlaryngoscopy and polyp removal with anterior commissure stripping in another patient. The third patient underwent emergent intubation for a small bowel obstruction 1 week after laryngeal laser vaporization of Teflon secondary to airway compromise. The subsequent web formation resulted in a considerably breathy and aphonic voice. The glottic web was rated according to the length of the vocal folds involved: type 1 (<50% of the membranous vocal fold), type 2 (the entire length of the membranous vocal fold), and type 3 (involvement of the membranous as well as cartilaginous vocal folds). Patients underwent preoperative and postoperative videostroboscopy (Kay Elementrics), as well as acoustical analysis, glottal flow measures, and perceptual analysis. The degree of hoarseness Journal of Voice, Vol. 12, No. 4, 1998
All three patients tolerated the keel well without any significant airway compromise. None of the patients complained of increased shortness of breath. All of the patients had improvement of their voices by perceptual measures (Table 2). However, only patient 1 experienced a dramatic improvement (objectively and perceptually) in her vocal quality. Her preoperative jitter (3.04), shimmer (1.20), and harmonic-tonoise ratio (1.18) all improved (1.27, 0.36, and 6.30, respectively). She had a type 1 web with a pinholesized opening preserving the anterior commissure. Patients 2 and 3 had slight improvement in their voices by perceptual measures only. Both patients had residual rounding of the anterior commissure without significant web re-formation. Patient 1 also had a solitary granuloma formation, which was removed subsequently on an outpatient basis. DISCUSSION Although the number of patients in this series is too few to make a conclusive judgment on the procedure, it appears that transoral placement of a glottic keel is safe and does not significantly interfere with respiration. However, voice results of transoral laser resection and keel placement are mixed. Patients with more severe fibrosis of the anterior commissure and the vibrating edge of the vocal fold may experience residual hoarseness despite adequate resection of the web and cord restoration. Other factors, such as the depth of the intracordal fibrosis, most likely play a significant role in these patients. The technique can be done safely on an outpatient basis, obviating the need for a transcervical approach and/or a tracheotomy. The keel may also be removed in the clinic with topical anesthesia and the aid of a nasopharyngoscope, utilizing the working channel and a small cupped forceps. The long-term results re-
OUTPATIENT TRAbISORAL LASER VAPORIZATION
539
T A B L E 1. Patient demographics, histo~. , and follow-up Follow-up (months)
Airway Compromise
Intubation 2-3 days
5
no
1
Direct laryngoscopy and polyp removal
2
no
2
Teflon laser vaporization and intubation 1 day
12
no
Patient
Age
Sex
Web type
I
42
F
2
2
68
M
3
65
M
Etiology
T A B L E 2. Preoperative and postoperative voice measures Preoperative
Postoperative
Patient
Hoarseness
Breathiness
1
3
3
Hoarseness
Breathiness
I
1
2
3
3
2
2
3
4
4
3
3
garding vocal quality and web re-formation are unknown. Further study is under way on a larger group of patients. In conclusion, the transoral endoscopic keel placement after web resection appears to be a safe alternative to transcervical approaches without any evidence of airway compromise.
REFERENCES I. McNaught RC. Surgical correction of anterior web of the larynx. Laryngoscope 1950;60:264. 2. Woodman D. Laryngeal stenosis. Lalyngoscope 1953;63:714 3. Haslinger E Ein Fall yon Membranbildung im Larynx. Eine neue Methode zu ihrer Behebung. Monatschr Ohrenheilk 1924;58:174. 4. Messerklinger W. Zur behandlung der kongenitalen synechien im glottisbereich. Monatschr Ohrenheilk 1964;98:194. 5. Mouney DE Lyons GD. Fixation of laryngeal stents. Lal3,ngoscope 1985;95:905-7.
6. Nessel E. Ein Vorschlag zur Vereinfachten Behandlung der Stimmlippensynechie. HNO 1968; 16:284 7. Dedo HH. Endoscopic teflon keel for anterior glottic web. Ann Otol Rhinol Lal3,ngol 1979;88:467. 8. Devgan BK, Lampros WP, Leach W. Endolaryngeal surgery for anterior glottic stenosis. Ear Nose Throat J 1976;55: 377-81. 9. Kleinsasser O. Mikrolal3,ngoskopie und Endolaryngeale Mikrochirurgie. Stuttgart, Germany: Schattauer, 1968. 10. Beck C. Einfache verfahren zur behandlung von stenosen der oberen luftwege. Arch Ohr Nas Kehlk Heilk 1962;180: 507. 1 I. Pennington CL. The treatment of anterior glottic webs: a reevaluation of Haslinger's technique. La~.ngoscope 1968;78: 728-41. 12. Alonso JM, Regules JE. Behandlung der angeborenen Membranen und der Synechien des vorderen Glotisabschnittes. Z La~ngol Rhhlol 1956;35:53. 13. Lichtenberger G, Toohill RJ. New keel fixing technique for endoscopic repair of anterior commissure webs. Latyngoscope 1994; 104:77 I-4.
Journal of Voice, Vol. 12, No. 4, 1998